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Postmenopausal bleeding (PMB) is defined as any uterine bleeding occurring after 12 months of amenorrhea in a woman of menopausal age. It is always considered abnormal and warrants prompt evaluation because of the risk of endometrial carcinoma.
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| Type | Cause |
|---|---|
| Genital tract causes | • Atrophic endometritis/vaginitis (most common; due to estrogen deficiency → fragile endometrium). |
| • Endometrial carcinoma (10–15% of cases). | |
| • Endometrial hyperplasia (with or without atypia). | |
| • Endometrial polyps. | |
| • Cervical pathology (cervical carcinoma, polyps). | |
| • Ovarian hormone-secreting tumors (granulosa cell tumors → unopposed estrogen). | |
| Non-gynecological causes | Urethral caruncle, hematuria, rectal bleeding (should be excluded). |
| Iatrogenic causes | • Hormone replacement therapy (HRT). |
| • Tamoxifen (selective estrogen receptor modulator, increases endometrial risk). | |
| • Anticoagulants. |
Transvaginal Ultrasound (TVUS):
| Parameter | Imaging features |
|---|---|
| Endometrial thickness (ET) | • ≤4 mm: endometrial carcinoma highly unlikely (<1% risk). Usually no biopsy needed if asymptomatic after single episode. |
| • >4 mm: requires endometrial sampling (biopsy, hysteroscopy). | |
| Other lesions | • Endometrial polyps (focal thickening). |
| • Submucosal fibroids. | |
| • Ovarian/adnexal pathology. | |
| Saline Infusion Sonohysterography (SIS) | Improves visualization of focal lesions (polyps, submucosal fibroids). |
Algorithm for suggested diagnostic strategies in women with postmenopausal bleeding (PMB) (some areas require further research). ET = endometrial thickness; HRT = hormone replacement therapy
Bakour SH, Timmermans A, Mol BW, Khan KS. Management of women with postmenopausal bleeding: evidence‐based review. The Obstetrician & Gynaecologist. 2012;14(4):243-249. doi:10.1111/j.1744-4667.2012.00129.x